MU Department of Physical Therapy
PT 8390 - Case Management II
The Geriatric Patient with Complications of Diabetes
Objectives: Diabetes Mellitus and Sequelae
The student will be able to:
1.
Compare and contrast the etiology, symptoms, pathophysiology, diagnostic methods, and management in Type I
and Type II diabetes in both lay and medical terms. Explain how the “3 polys” are related. Compare the
usefulness of blood sugar (BS) readings and glycosylated hemoglobin (HbA1c) and give normal values for each.
State epidemiology rates of DM for ethnic groups.
2.
For a non-diabetic person (or for a person with diabetes with excellent management): give expected blood sugar
levels, and explain the normal homeostatic relationship of insulin & glucose with glucogon & glycogen through
the normal cycles of pre-meal and then post-meal (postprandial). Relate this to anticipated BS levels before a
meal, and the time after a meal. Describe the normal response to exercise and also the circumstances that create
ketone bodies and ketoacidosis. Recognize the purpose and normal values of lab measurements for Albumin
(urine sample) and for Creatinine (blood sample). For each test, state whether high or low values are a concern.
3.
Review the relationship of diabetes with other chronic conditions, and contrast the effect of good or poor control
on the development of these sequelae: kidney disease, retinopathy, atherosclerosis, peripheral neuropathy.
Appreciate these as likely clinical features of diabetes, rather than unrelated co-morbidities. Describe the
additional measures that need to be taken in the rehab environment as a result of these impairments.
4.
List the pathological results of autonomic neuropathy secondary to diabetes as manifested in the following
systems: metabolic, CV, neurovascular. Describe the implications of these impairments for the rehab
environment.
5.
Clarify role of physical therapy for a person with end stage renal disease ESRD. Appreciate how different
methods of dialysis will result in different levels of rehab potential, i.e. Hemodialysis (performed in an out patient
clinic) and Peritoneal dialysis (performed by the patient in their home)
6.
Clarify the role of physical therapy for a person following kidney transplant.
7.
Discuss vision changes that occur normally with aging, as well as pathological changes. Describe in lay terms
symptoms that patients should be aware of. Outline recommendations for assisting someone who is blind or
vision impaired.
8.
Demonstrate familiarity with the tools used in a formal Driving Assessment. Describe functional changes in
aging that have an impact; common errors made by elderly drivers; possible compensations and restrictions; and
the professional responsibility in this matter. Resources will be posted on the course website.
9.
Recognize types of oral medications used in diabetes by generic names, common brand names, and classify them
into various categories of action. Explain at what point oral medication may be prescribed for Type II diabetic
persons. Type I diabetics may be prescribed oral meds “off label”. This can occur in an older Type I patient who
has secondarily developed increased glucose intolerance, commonly as a result of obesity. Oral meds can help the
person with Type I to use less insulin and have better glycemic control.
10.
Recognize categories of insulin and explain generally how insulin is prescribed and administered.
Identify injection sites, and how these may need to be modified for certain types of exercise.
Recognize that insulin may be prescribed not just for Type I diabetics, but also in some cases for brittle (poorly
controlled) Type II diabetics.
Discuss the operation, and the advantages and disadvantages of Continuous Subcutaneous Insulin Infusion (CSII),
“Insulin Pump”.
What does it mean that exercise has an insulin-like effect? What are the implications of this?
11.
Discuss current research / clinical practice guidelines for both categories of diabetes related to prevention and
control.
12.
Given a diabetes patient description, including medications, preferred dietary program, and desired exercise
activities, demonstrate understanding of principles of management by recognizing or recommending an
appropriate exercise program, including all safety precautions.
13.
Contrast symptoms of hyperglycemia / ketoacidosis with hypoglycemia / insulin shock. Given an emergency
situation in a home health setting, determine appropriate steps in a situation when you have access to a glucometer
reading, and in a situation when no glucometer reading is available. For the same patient, describe appropriate
steps if the patient is unconscious.
14.
Describe how you would perform a differential diagnosis of vascular claudicating pain vs. neurogenic
claudicating pain (e.g. spinal stenosis) vs. DVT vs. musculoskeletal pain
(see Goodman p.745-746 leg pain; p.655-660 back pain – leg pain)
15.
Describe exercise intervention for vascular claudicating pain (intermittent claudication). Include rationale for
the protocol in both medical and lay terms.
16.
Discuss differences in chronic wounds (etiology, co-morbidities, location, appearance, exudates, pain) caused by:
venous insufficiency / arterial insufficiency / loss of sensation (e.g. diabetic foot ulcers) / pressure (decubitus)
ulcer. Which conditions would COMMONLY co-occur? State when it would be appropriate to elevate or give
compression to the LEs and when it would not be appropriate.
Briefly compare and contrast the arterial and venous system by addressing: capacity, active vs. passive, and
responsiveness to pharmacologic intervention.
Recall that venous circulation is passive and a large capacity. Recall that arterial circulation is active (muscular layer
within the vessel lining that will respond to vasodilator drugs) and has a smaller capacity relative to the venous system.
17.
Describe a foot evaluation that includes neurological, vascular, integumentary, and orthopedic/structural components.
18.
Outline a program of foot self-care for a person with diabetes living independently. Discuss the hazards related
to insensitive legs and feet; describe how a developing plantar ulcer may be recognized.
19.
Make recommendations regarding management of a plantar ulcer: wound care; mobility; footwear. Generalize
knowledge about diabetic foot management to other conditions associated with plantar ulcers, including Hanson’s
Disease (leprosy) and thromboangiitis obliterans (Buerger’s Disease)
Describe footwear options, modifications, inserts, orthotics, and assistive devices for a person with:
20.
21.
22.
23.
24.
25.
26.
27.
28.
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non-healing plantar ulcer
normally healing plantar ulcer
foot deformities (hammer toes, hallux valgus)
toes amputated / transmetatarsal amputation
Charcot arthropathy
State uses of a Total Contact Cast (TCC). Contrast the composition and function of a TCC to an Unnas Boot.
Briefly describe 2 theories on the etiology of Charcot Arthropathy. Describe early S/S, the typical course of the
process, and (non surgical) interventions. Differentiate Charcot Arthropathy from Charcot Marie Tooth (an
inherited condition).
Describe the effect of a transmetatarsal amputation on gait, and the risk of further breakdown. Recommend
methods of management that help minimize further complications.
Review LE Amputation: PT management, educ, pre-gait, gait training, prostheses.
Describe Buerger Allen exercise protocol, and it proported usefulness. Understand that is efficacy is
controversial.
When offering assistance to a person who is blind to help them navigate an unfamiliar environment, demonstrate
proper body position and manual contact.
Briefly explain how the respiratory and metabolic systems maintain blood pH homeostasis and how this is tracked
by observing Arterial Blood Gasses (ABG). (This is re-visiting the objective from the Pulmonary unit in CM I,
and this time putting it in the context of the diabetic person with blood sugars over 300 who would be in a
hyperglycemic, possibly ketoacidotic state.)
Using the principal of Glycemic Index (GI), describe an optimal diet for the person with metabolic syndrome,
and also for the person with diabetes. Information and a GI Diary assignment are on the course website.